Provider Demographics
NPI:1639332240
Name:TRUMBULL MAHONING MEDICAL GROUP INC
Entity Type:Organization
Organization Name:TRUMBULL MAHONING MEDICAL GROUP INC
Other - Org Name:TMMG URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:MOURAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-372-8820
Mailing Address - Street 1:2600 ELM ROAD NE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410
Mailing Address - Country:US
Mailing Address - Phone:330-372-8895
Mailing Address - Fax:330-372-8999
Practice Address - Street 1:2600 ELM RD NE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9393
Practice Address - Country:US
Practice Address - Phone:330-372-8820
Practice Address - Fax:330-372-8999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUMBULL MAHONING MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0468677Medicaid
PA1426141OtherHIGHMARK OF PA
OH000000243183OtherANTHEM
PA1426141OtherHIGHMARK OF PA
OH=========025OtherMEDICAL MUTUAL OF OHIO
OH0468677Medicaid